A Sunday Conversation With an Interventional Cardiologist

It all started as a simple text message. An interventional cardiologist from a rural area had some questions about PAE. It’s not the first time, nor do I suspect it will be the last time that other vascular specialists will have questions about some of the magical things we can do in interventional radiology.

Generally speaking, I’m pretty protective about what we do in IR. You can probably get that from the text message. While I’m pretty mild mannered in person, I know what’s at stake here and am not afraid to stand my ground for what I feel is right. We train very hard to acquire a unique skillset that frankly the majority of us in IR are not leveraging to the maximal potential possible to do the greatest good for society. At the same time, I’m seeing many other vascular specialists take on work that was historically under the purview of interventional radiology.

So while I had my suspicions, I am in no place to judge what the motivations of this individual are from a simple text message. You might be wondering how or why a device representative would connect me with this interventional cardiologist. Well the back story is I did a prostate artery embolization at my locums job in the upper Midwest. Contrary to popular belief regarding locums work in community hospital settings, there is a clinic at this site where the two other IRs and I see patients. I have committed to working with this group for 32 weeks this year, so naturally I felt it was worth my time to establish my own clinical presence and find ways to add value to the local practice here. My way of doing so is to help grow the prostate artery embolization practice and teach my IR colleagues who in turn teach me plenty from their collective 50-year experience doing IR. I am actively establishing relationships with urologists here and have voluntarily given a grand round talk in the hospital. Hard work is paying off, slowly, and we are starting to get more referrals. When the time comes for me to leave and for another IR to join this practice, I will do my best to facilitate that transition because at the end of the day, I want to see thriving IR practices in the community where our services are most needed.

I ended up doing a PAE case, but needed a device rep present because the typical pushable coils I use for these (3-2 Tornado if anyone is interested), could not be obtained in time so I decided to use detachable coils for any potential shunts even though they’re frankly not necessary in these cases. I had a motivated and friendly device rep new to embolization who wanted to learn more attend. I also had some techs and nurses also interested in learning. So I did what I know best, which was to teach as much as I could while doing the case which went smoothly and efficiently.

Of course, as soon as I got done, one of the senior IRs came up to me and said while he thought it was great I was doing this case and teaching others, he was suspicious of the fact that a device rep was present. Before you know it, cardiologists and surgeons will begin doing these cases and there will be nothing left for us but PICCs and paras. Be careful man!

In hindsight I could see where he was coming from because he has lived through the devaluation of IR services as procedures have been lost to other fields. Initially though, I thought his comment was frankly hilarious because I thought to myself that most IRs don’t have the patience to make it through a PAE yet alone put in the hard work to develop a PAE practice…there is no way a vascular surgeon or cardiologist would ever try doing this especially since they have all sorts of other things they could be doing.

Look, if you haven’t done a PAE, or seen a PAE, they are one of the most technically challenging procedures we do in IR. It takes significant time and dedication to not only build a PAE practice, but to get halfway decent at doing these cases. Considering that the embolization code is the same as it is for UFE with fewer commercial payers given patient demographics, most IRs are not financially incentivized to take on this work even though it is much needed. And this of course is to not even mention the fact that many hospital-based private practice radiologists are not interested in taking on “big cases” due to the dynamics and economics of hospital-based radiology which I have discussed before.

Well, needless to say, I was a little surprised when a month later I got a text from this device rep asking that I talk to this interventional cardiologist. Part of me was defensive. Part of me was just curious. So I thought to myself, what do I have to lose really?

I called him and we had probably the most enlightening conversation that I’ve had in a while. The cardiologist, who is a busy hospital employed interventionalist, was approached by the local urologists to take on prostate artery embolization. They have a large volume of elderly anticoagulated patients with indwelling Foley catheters and are keen on having this service available in this community which serves a catchment area of roughly 500,000 in literally the middle of nowhere. My mind was blown. Per this cardiologist, the interventional radiologists were too busy and not interested in taking on this line of work. He has called on the IRs to help him out with things like type 2 endoleaks and other vascular cases in the past, but they seem to not be interested in playing ball. In fact, they used to do a large volume of superficial venous disease but apparently voluntarily gave that up too. When I asked him what his IRs were doing all day, he told me I guess reading studies. Upon further questioning, it turns out the interventional radiologists are part of a private radiology group which contracts with the hospital. I have no doubt that the IRs are hospital MVPs and trash collectors.  Pretty typical arrangement.  

This cardiologist is well-trained, having done a 1-year interventional cardiology fellowship and an additional fellowship in peripheral vascular interventions. In fact, he was trained in peripheral interventions by one of the most famous interventional cardiologists in the peripheral space in New York City. In this particular institution IR, IC and VS seem to work well and there is great cross-pollination, or at least there was at the time this individual trained. It happens to be the same institution employing an accomplished IR who recently critiqued my commentary regarding the realities of hospital based interventional radiology in most community settings. The cardiologist seriously had truly wonderful things to say about this individual as he praised him for his teaching. You can read the SIR Connect forums for more on that backstory.

What was actually refreshing about this conversation was the fact that this cardiologist acknowledged his limitations. His knowledge of pelvic arterial anatomy and cross-sectional imaging is clearly nowhere close to that of an IR and he realizes that there are tremendous concerns with him taking on this work. He was reaching out to me not necessarily to learn how to do PAE, but he wanted to know what’s involved so he can make an educated decision as to whether or not he should take on this line of work. Keep in mind this all resulted from a urologist asking him to help and that his own opportunity cost is quite high as he is a busy interventional cardiologist with no shortage of work in a community that has a hard time attracting subspecialist physicians.

I made it very clear that prostate artery embolization is not to be taken lightly. There are serious consequences that can arise from non-target embolization. If he is to take up prostate artery embolization, then by extension we in IR should be able to take on coronary arterial interventions. Of course, conveniently ignoring the 6 years of very important non-procedural training it takes to get to the point where an aspiring interventional cardiologist even learns to contemplate placing a coronary stent. When you put it like that, it is clear where the lines need to be drawn. To this individual’s credit he acknowledged that and we had a really productive conversation.

It turns out that he and I have a lot more in common than not. He works hard in the hospital doing coronaries and very important CLI work in an area with a high amputation rate. He wants to learn more about the OBL space. He wishes he had IRs he could truly collaborate with. More than anything, he’s just a nice guy who is doing due diligence on a procedure he doesn’t know anything about.

I have conversations like these with other vascular specialists every so often. They’re often facilitated by device representatives. Generally it’s because these other specialists are looking to bring on an IR to grow a service line, but rarely you get a cowboy who really wants to do embolization and is looking to pick your brain. While it’s easy to blame the reps for “revealing our secrets to our competition”, let’s not kid ourselves. They’re just trying to do what they do in sales which is facilitate relationships and close deals. If the climate is such that there isn’t an IR willing to use their device, they’ll do what they need to do to survive. It’s how they make a living. Don’t hate the player, hate the game, right?

Well, yes indeed. Let’s spend some time talking about this “game.” And no, I’m not talking about the device rep game (most definitely a post for another day).  I’m talking about the game in which interventional cardiologists and vascular surgeons “steal” our procedures. Anyone in IR knows exactly what I’m talking about.

My IR fellowship in the 1990s was all about vascular. In fact, we did more angiograms than non-vascular procedures.

This is what one of my senior colleagues told me recently. It’s very funny because when I talk with my wife about her vascular surgery fellowship experience, it almost sounds like a 1990s IR fellowship with the occasional open procedure. Many vascular surgeons in training seriously worry about their open experience, but don’t sweat endovascular at all. Why is this the case?

I have my own interesting take on this which I have spent a lot of time contemplating. I wrote this article in 2020 and it received a tremendous amount of criticism by many in the IR Twitterspace. I truly question the conflicts of interest and overall political motivations of those who have concerns with my argument.  

The cold truth is nothing we do in IR is truly sacred, including the interventional oncology work that many claim is our primary focus now as a field. We have some truly excellent settings in academics (I think I can name only 2 off hand) where there is true multidisciplinary collaboration between the big 3 vascular specialists. These are settings where cross-training of fellows works because each division has a strong clinical presence and there is some degree of political savvy among all major players to make it work. The problem is this is not how the real-world functions and expecting IR trainees to replicate this experience by conveniently ignoring the economic drivers of common IR practice patterns is frankly disingenuous and just plain dangerous for the future livelihood of our wonderful field.

In fact, I would argue that these same people partaking in the cross-training on the IR end conveniently ignore the number one issue which is the root of 99% of our problems in interventional radiology. It’s the radiology part. When you cross train vascular surgeons or interventional cardiologists in procedures which have historically been performed by IR and then these individuals go out into communities where IRs do not have a clinical presence, what do you think will happen? Next thing you know, a urologist will ask if they can help out with PAE full well knowing that IR has not been helpful in the past and the cardiologist they are asking is the go to endovascular specialist in that setting.

And while we may want to think that some of these vascular surgeons and cardiologists are truly malignant leeches stealing procedures (and yes in some settings a few of them are though I would argue that this behavior is reflective of overtly aggressive players in a faulty wRVU based system in general), the real reason our procedures are “stolen” is because we have done nothing to protect them.

We need to be collectively ashamed of ourselves. This is a problem we created for ourselves. Remember, interventional radiology played a critical role in the development of current endovascular techniques. Our professional society was once upon a time the Society of Cardiovascular and Interventional Radiology and Society of Cardiovascular Radiology before that. Looks like the cardiovascular part of it disappeared. But it’s ok, there’s all sorts of great things we can still do, right? Like prostate artery embolization! Or so one would think.

We need strong interventional radiologists in our communities truly adding value to the physicians and patients they serve. If this interventional cardiologist I spoke with had a strong clinically motivated independent interventional radiologist on the ground that they could rely on, or compete with, I bet you this would not be a problem.

So does anybody want to move to this community and provide this much needed service? Well let’s say you are interested. You decide to join this interventional cardiologist and you open an OBL or you do it on your own. Guess what? That radiology group which has IRs who are not keen on performing PAE likely won’t let you get hospital privileges. Pseudoexclusive contracts. Yes, this has been beaten to death before, but I will continue to do so because I want every reader to know how messed up this game is in IR.

But no, we will continue to have Academic Gaslighting by our society leaders who tell us we need to simply try harder to “break the mold.” What is not being told are how many of these leaders are in bed with Big Radiology (ACR and ABR), the same organizations which value us as IRs functioning within a hospital-based radiology context while blissfully ignoring the lack of financial alignment between IR and DR in the vast majority of these settings. It’s a financial relationship which truly hinders the development of clinical practices. These IR leaders help train other vascular specialists along with talented IR trainees only to result in two of the three specialties starting well ahead of IR in the basic infrastructure needed for a clinical practice.  

The cycle continues and will continue until we acknowledge the key shortcoming in our field which prevents us from developing clinical practices at scale. Our business relationship with radiology is the key detriment to the development of true clinical practices. Training is a close second, though that is changing for the better. Ultimately, it all comes down to money. Ego and politics are tied for second place. This is a message even the most progressive academic IRs will not tell you. It isn’t because they’re all purposefully hiding something from you, though some may. Poking the bear has significant political consequences and unless you’re in a position where you truly don’t care and/or are financially independent, nobody wants to do something which can have negative career consequences.

For the trainees reading this, please realize that this is my opinion only and does not reflect the views of the SIR (obviously) or frankly many practicing interventional radiologists who are happy in their professional settings. You should talk to some of these people to get their side of things. Then come back here and realize that there is far more truth than lies in what I have to say. Also keep in mind that many of these practicing IRs, who you won’t see on Twitter, are living in a model which is going to experience decline over the coming decades. And the ones that you do see on Twitter are largely in academic practices or exist within harmonious radiology groups with an IR clinical presence (more the exception than the rule as any glance at an SIR/ACR job board would suggest). These issues which I mention are particularly relevant to you if you decide to partake in a clinical model where you want compete, or collaborate, with other vascular specialists. This is the future of our field. But you need to understand where you stand in the big picture relative to competing vascular specialists coming out of training and know what it takes to carve out your presence. You need to learn to do this so you’re not purely dependent on luck, circumstance or many years of butting heads in a hospital setting to achieve your desired clinical practice. Part of my mission is to help you carve out that presence as I learn the hard lessons doing it in real time as an independent IR. 

More to come soon.